San Francisco Marin Medical Society Blog

SFDPH Health Alert: Rising Rates of Syphilis Among Pregnant Women

Health Alert: Rising Rates of Syphilis Among Pregnant Women

May 22, 2019

Situational Update
In 2018 compared to 2017, there was an 88% increase in San Francisco of reported syphilis cases among women (from 64 to 120 total cases), the majority of which were among women of childbearing age. Approximately 30% of female syphilis cases reported experiencing homelessness, 35% reported methamphetamine use and 13% were diagnosed in emergency departments or urgent care settings.

Given rising rates of syphilis in women in San Francisco and rising rates of congenital syphilis across California, we are now recommending that all pregnant women be tested for syphilis at least twice during pregnancy.

Actions Requested of Clinicians

  1. For all pregnant women, test for syphilis at least twice during pregnancy: 1) at the first clinical encounter (ideally during the first trimester) and 2) during third trimester (ideally between 28-32 weeks gestation). Women with risk factors for syphilis should be tested a third time at delivery. Infants should not be discharged from the hospital unless the mother has been tested for syphilis at least once during pregnancy.
    • Risk factors for syphilis in women include substance use, homelessness, sex work, sex in exchange for money, housing or drugs, intimate partner violence, a history of incarceration, or sex with a partner who may be at risk for syphilis.
  2. Penicillin (benzathine penicillin G [Bicillin LA] 2.4 mu IM) is the only therapy proven to be effective in pregnancy. Treatment at least 30 days before delivery is 98% effective at preventing congenital syphilis. Additional information regarding the diagnosis and treatment of syphilis is available at or by calling San Francisco City Clinic at 415-487-5595.
  3. Test individuals who report methamphetamine use or are experiencing homelessness for syphilis, HIV, and HCV, including in emergency room and urgent care settings in order to avoid missed opportunities for screening.
  4. For all women who test positive for syphilis: 1) treat immediately, 2) obtain a pregnancy test if not known to be pregnant, 3) offer women HIV PrEP or PEP, 4) and obtain updated cell phone numbers and hangouts and inform women that the SFDPH LINCS team will reach out to them to help partners get tested and treated. LINCS partner services are voluntary and offered by skilled and client-centered DPH staff. Please encourage patients to work with us at DPH to prevent ongoing syphilis in San Francisco.
    • Report suspected syphilis cases within 24 hours of identification and let the SFDPH LINCS team know if a woman needs outreach to ensure treatment. Call 415-487-5531 or fax a confidential morbidity report ( to 415-431-4628.

Additional Guidance Related to the Increase in Syphilis Among Women
Historically, congenital syphilis increases when cases of syphilis among women of childbearing age increase. Congenital syphilis can cause severe illness in babies, including premature birth, low birth weight, birth defects, blindness, and hearing loss. It can also lead to stillbirth and infant death. Prevention relies on early detection of unrecognized syphilis in the pregnant woman, detection of newly acquired syphilis during pregnancy, and ensuring completion of maternal treatment at least four weeks before delivery. All women presenting with any of the following symptoms should be tested for syphilis immediately: generalized maculo-papular rash, a palmar plantar rash, genital or rectal sore or lesion, moist papules in the genital or rectal regions, or patchy hair loss. All patients being evaluated for syphilis should be tested for HIV infection.

  • False negative RPRs can occur in the setting of high RPR titers. If you suspect syphilis and the RPR result is negative, ask the lab to check for prozone phenomenon on the original sample.
  • A positive RPR and negative treponemal test (i.e. TPPA) indicates a false positive, and does not require additional evaluation.
  • Many labs are now screening for syphilis with a treponemal test called an EIA. The EIA is then confirmed with an RPR. If the EIA is positive and the RPR is negative, the lab should run another treponemal test (usually, a TPPA). If the EIA is positive, RPR negative and TPPA negative, this indicates a false positive and does not require additional evaluation. For more information on interpreting syphilis serologies: call the City Clinic provider line at 415-487-5595.
  • Initiate penicillin therapy in all patients with symptoms of syphilis and those who report sexual contact with someone who has syphilis without waiting for laboratory confirmation of the diagnosis.

Additional Guidance Related to STD Prevention in Men Who Have Sex with Women
Ask all men diagnosed with syphilis, regardless of reported sexual history, if they have any sex partners who are pregnant or could become pregnant. SFDPH LINCS will help ensure testing and preventive treatment for female partners of men who are diagnosed with syphilis.

Important STD Prevention Numbers and Resources

  • Syphilis titer and treatment history and referrals to DPH LINCS partner services: 415-487-5531
    • It can be difficult to inform partners after an STD diagnosis. As providers, your role is critical to preparing patients for the call from LINCS partner services. Please routinely inform patients that the LINCS team will call them to help identify partners who could benefit from free HIV/STD testing and preventive syphilis treatment.
  • San Francisco City Clinic provider line for clinical questions: 415-487-5595
  • San Francisco City Clinic PrEP line: 415-487-5577
  • San Francisco STD screening guidelines: website, search “For Providers”
  • CDC 2016 STD Treatment Guidelines:, also download the CDC Treatment Guideline App

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